Daryll Jeremy Fagela-Virtudes NCM 116 SL

BSN-3F

INCREASED INTRACRANIAL
PRESSURE
- DEFINITION -
Intracranial pressure (ICP) is a reflection of the total volume inside the skull. Normal
ICP is 0 to 10 mm Hg. Intracranial hypertension is defined as sustained ICP of more than 20
mm Hg. Increased ICP may lead to a reduction of cerebral perfusion pressure (CPP), a shift
of brain tissue, and, as a result, secondary brainstem injury. Monitoring of increased ICP
provides the opportunity to effectively treat damaging pressure waves and is needed to
prevent irreversible damage. The 3 constituents of intracranial volume are the brain, cerebral
spinal fluid (CSF), and blood. These elements sit within the fixed volume of the skull. If one
of these 3 components increases in volume, the other 2 must compensate by reducing volume.
If they cannot compensate, ICP increases (Woesnsner & Freeman, 2015).
- CAUSES -

Bleeding Swelling High

Aneurys Hydrocep
into the in the Stroke Blood
brain m halus
Pressure
brain

Blood pooling in Brain or

some part of the head Brain tumor
brain injury

Too much cerebrospinal fluid (the fluid around your brain and spinal
cord)

- SIGNS AND SYMPTOMS -

Cushing's Triad

an increasing gap
between your
irregular breathing systolic and a drop in your
patterns diastolic blood heart rate
pressures (widened
pulse pressure)
Daryll Jeremy Fagela-Virtudes NCM 116 SL
BSN-3F

- Other Signs and Symptoms -

Nausea
Headache and
Vomiting

Decresea
Increa d Mental
sed BP Ability

Doubl
Confus
e
ion Vision
Pupils that
don’t
respond to seizure
changes in
light

loss of
conscio coma
usness

- MANAGEMENT –

Nursing Assessment

Monitor Temperature
Frequent neuro and hemodynamics, Check Laboratory
checks (q1h) including MAP and Test such as CPP
CPP
Daryll Jeremy Fagela-Virtudes NCM 116 SL
BSN-3F

- NURSING RESPONSIBILITIES –
o Administration oxygen as order
o Give medication therapy as order
o Maintain Nutritional and food status
o Maintain Diet plan give soft and healthy meal according to direction order
o Suction only as needed
o keep the patient in semi-Fowler’s positions
o promote healthy and comfortable environmental
o educate clients about every kind of procedure
o assist with turning, coughing, and deep breathing
o Maintain the position and patency of the NG tube
o Enforce bed rest
o promote mouth care and skin care
o Maintain skin care change position every hourly to prevent bed sore
o Maintain seizure precautions
o Provide emotional support client’s and his family